Sentinel surveillance for patients with acute hepatitis in Egypt, 2001-04.

Viral hepatitis is a major problem in Egypt. To define the epidemiology of the disease, sentinel surveillance was established in 5 hospitals in diverse areas of the country in 2001. Data were completed for patients meeting the case definition for viral hepatitis. Of a total of 5909 patients evaluated, 4189 (70.9%) showed positive antibody markers for hepatitis. Out of those, 40.2% had evidence of hepatitis A virus (HAV) infection, 30.0% hepatitis B virus (HBV) and 29.8% hepatitis C virus (HCV) infection. This surveillance system was useful in identifying the variable endemicity of acute HAV infection in different regions and for better understanding the epidemiology of HBV and HCV infection.

Case-control study to evaluate risk factors for acute hepatitis B virus infection in Egypt.

Hepatitis B virus (HBV) infection is a significant health problem in Egypt. To better define risk factors associated with HBV transmission, we conducted a case-control study among patients admitted with acute hepatitis to an infectious disease hospital in Cairo. A total of 60 cases and 120 controls were interviewed about various exposures within 6 months prior to admission. Univariate analysis revealed HBV case-patients were more likely to report providing injections to relatives or friends, injecting drug use, exposure to a household contact with hepatitis, exposure to invasive medical procedures and being in the military. Efforts should be made to implement strict infection control standards in Egypt.

Sentinel surveillance for patients with acute hepatitis in Egypt, 2001-04

Viral hepatitis is a major problem in Egypt. To define the epidemiology of the disease, sentinel surveillance was established in 5 hospitals in diverse areas of the country in 2001. Data were completed for patients meeting the case definition for viral hepatitis. Of a total of 5909 patients evaluated, 4189 [70.9%] showed positive antibody markers for hepatitis. Out of those, 40.2% had evidence of hepatitis A virus [HAV] infection, 30.0% hepatitis B virus [HBV] and 29.8% hepatitis C virus [HCV] infection. This surveillance system was useful in identifying the variable endemicity of acute HAV infection in different regions and for better understanding the epidemiology of HBV and HCV infection

Case-control study to evaluate risk factors for acute hepatitis B virus infection in Egypt

Hepatitis B virus [HBV] infection is a significant health problem in Egypt. To better define risk factors associated with HBV transmission, we conducted a case-control study among patients admitted with acute hepatitis to an infectious disease hospital in Cairo. A total of 60 cases and 120 controls were interviewed about various exposures within 6 months prior to admission. Univariate analysis revealed HBV case-patients were more likely to report providing injections to relatives or friends, injecting drug use, exposure to a household contact with hepatitis, exposure to invasive medical procedures and being in the military. Efforts should be made to implement strict infection control standards in Egypt

Factors associated with student participation in a school-based hepatitis B immunization program.

This study examined the relationship between participation in a school-based hepatitis B immunization program and teacher attitudes toward school-based health care and student socioeconomic factors. A survey addressing teachers' attitudes was administered to all teachers participating in the program. Information regarding student participation in school lunch programs and scores on national standardized tests were collected. Of the 4,874 fifth-grade students targeted for the program, 3,483 (72%) consented to be vaccinated and 3,232 (93% of 3,483) received all three doses of vaccine. Socioeconomic factors were the most important predictors of student participation in this school-based immunization program. Participation was significantly lower among students in schools with a high proportion of students receiving free or reduced-price school lunch and with low test scores. The only teacher factor associated with student participation was whether the teacher had returned the questionnaire. Strategies to increase immunization coverage in school-based programs should target children of low socioeconomic status.

Progress in coverage with hepatitis B vaccine among US children, 1994-1997.

OBJECTIVES: This study was done to assess progress in hepatitis B vaccination of children from 1994 through 1997. METHODS: We used data from the National Immunization Survey (NIS), a random-digit-dialed telephone survey that includes a mail survey to verify vaccination providers' records. The NIS is conducted in 78 geographic areas (50 states and 28 selected urban areas) in the United States. RESULTS: A total of 32,433 household interviews were completed in the 1997 NIS. An estimated 83.7% of children aged 19 to 35 months received 3 or more doses of hepatitis B vaccine. Coverage with 3 doses was greater (86.7%) among children in states that had day care entry requirements for hepatitis B vaccination than among children in states without such requirements (83.0%) and was greater among children from families with incomes at or above the poverty level (85.0%) than among children below the poverty level (80.6%). Hepatitis B vaccination of children increased from 1994 through 1996, from 41% to 84%, but coverage reached a constant level of 84% to 85% in 1996/97. CONCLUSION: Although substantial progress has been made in fully vaccinating children against hepatitis B, greater efforts are needed to ensure that all infants receive 3 doses of hepatitis B vaccine.

Update on diagnosis, management, and prevention of hepatitis B virus infection.

Acute and chronic hepatitis B virus (HBV) infection is a leading cause of liver disease worldwide. It is estimated that approximately 350 million people worldwide have chronic HBV infection and that 1 million persons die each year from HBV-related chronic liver disease. In the past decade, significant progress in the understanding of the molecular virology and pathogenesis of HBV infection has been made. In addition, effective treatment modalities have been developed for persons with chronic infection. Worldwide, prevention of HBV transmission has become a high priority. In 1992, the Global Advisory Group to the World Health Organization recommended that all countries integrate hepatitis B vaccine into national immunization programs by 1997. Currently, 80 countries have done so and several others are planning to. Many countries have reported dramatic reductions in the prevalence of chronic HBV infection among children born since the hepatitis B vaccine was introduced into infant immunization schedules. Recent reports from Taiwan indicate a reduction in the incidence of liver cancer among children as a result of widespread hepatitis B vaccination programs.

Progress toward elimination of hepatitis B virus transmission in the United States.

The strategy to eliminate hepatitis B virus (HBV) transmission in the United States is comprised of the following components: (1) preventing perinatal transmission, (2) routine infant vaccination, (3) catch-up vaccination of children in high-risk groups at any age, (4) catch-up vaccination of all children at 11-12 years of age and (5) vaccination of adolescents and adults in high-risk groups. According to recent surveys, > 85% of pregnant women are screened for hepatitis B surface antigen (HBsAg). Of infants born to HBsAg-positive women identified in 1995, 93% received appropriate immunoprophylaxis at birth; however, only 69% were fully vaccinated by 6-8 months of age. From 1991 (when routine infant hepatitis B vaccination was first recommended) to 1996, the proportion of 19-35-month-old children who have received three doses of hepatitis B vaccine has increased from < 10 to 83%. During this time, rates of acute hepatitis B in children 7-10 years of age have declined by 27% and rates among children 3-6 years of age have declined by 62%. Implementation of programmes for catch-up vaccination of all adolescents at 11-12 years of age and for vaccination of adolescents and adults in high-risk groups have only recently begun and no data are available to assess the progress of these programmes. However, 26% (13/50) of states now have laws requiring adolescents to be vaccinated in order to enter school. Current data indicate that substantial progress has been made in implementing a strategy to eliminate HBV transmission in the United States. Future efforts need to be focused on improving complete immunoprophylaxis of infants of HBsAg-positive mothers, increasing vaccine coverage among 11-12 year old children and implementing programmes to vaccine adolescents and adults in high-risk groups.

Progress toward the elimination of hepatitis B virus transmission among health care workers in the United States.

BACKGROUND: Hepatitis B virus (HBV) infection is a well-recognized occupational risk for health care workers (HCWs). Vaccination coverage, disease trends, and the need for booster doses after hepatitis B vaccination of adults have been the subject of intense study during the 15 years of the vaccine's availability. METHODS: Vaccination coverage of HCWs was determined from a review of medical records on a sample of employees from 113 randomly selected hospitals. The number of HBV infections among HCWs and the general US population for 1983 through 1995 was estimated from national surveillance data. Studies on long-term protection after hepatitis B vaccination of adults were reviewed. RESULTS: A total of 2837 employee medical records were reviewed; 2532 employees (90%) were eligible to receive hepatitis B vaccine, and 66.5% of them (95% confidence interval, 61.9%-70.9%) had received 3 doses of hepatitis B vaccine. Vaccination coverage was highest (75%) for personnel with frequent exposure to infectious body fluids (phlebotomists, laboratory personnel, and nursing staff) and lowest (45%) for employees at low risk for exposure (dietary and clerical staff). The number of HBV infections among HCWs declined from 17,000 in 1983 to 400 in 1995. The 95% decline in incidence observed among HCWs is 1.5-fold greater than the reduction in incidence in the general US population. Studies on long-term protection demonstrate that vaccine-induced protection persists at least 11 years even when titers of antibody to hepatitis B surface antigen decline below detectable levels. CONCLUSIONS: Although a high percentage of HCWs have been fully vaccinated with hepatitis B vaccine, efforts need to be made to improve this coverage. There has been a dramatic decrease in the number of HBV infections among HCWs who are now at lower risk of HBV infection than the general US population. Vaccine-induced protection persists at least 11 years and booster doses are not needed at this time for adults who have responded to vaccination.

Prevention of hepatitis A virus infection.

Hepatitis A virus infection is major cause of acute hepatitis in the United States, accounting for approximately 75,000 cases of clinical illness each year. These infections occur among persons in every age group and are associated with a variety of exposures related to fecal-oral transmission. Recently, the U.S. Food and Drug Administration approved licensure of two inactivated hepatitis A vaccines. Both vaccines are highly immunogenic and have been licensed in pediatric and adult formulations. The prevention of hepatitis A virus infection is directly related to many aspects of family practice, and family physicians may see patients in a variety of settings that warrant administration of hepatitis A vaccine. Groups for whom vaccination is currently recommended include international travelers, children in communities with high rates of hepatitis A virus infection, men who have sex with men, Illicit drug users, patients with chronic liver disease and persons with clotting factor disorders.

Progress toward integrating hepatitis B vaccine into routine infant immunization schedules in the United States, 1991 through 1994. Connecticut Hepatitis B Project Group.

OBJECTIVE: We assessed progress toward universal infant immunization against hepatitis B, which was first recommended in November 1991. METHODS: Multiple data sources were used to describe vaccination policies and trends in infant hepatitis B vaccine coverage. RESULTS: As of June 1993, 51% of the 63 local, state, and territorial immunization programs recommended hepatitis B vaccination of all newborns shortly after birth. The number of first dosages of hepatitis B vaccine administered to infants in public sector clinics increased rapidly from late 1992 to 1993, and at the end of 1993 was approximately two thirds the number of first dosages of other infant antigens. In a nationwide survey of hospital nurseries 47% offered hepatitis B vaccine to all newborns. Of 3982 sampled newborns in these hospitals, 36.2% had been vaccinated before discharge. In San Francisco and Connecticut, where public health officials encouraged hospitals to offer hepatitis B vaccination, first-dose coverage at discharge was 82.3% in 1994 and 69.1% in 1993, respectively. Coverage was higher in healthier infants and lower in infants of older or better-educated mothers. Results from the National Health Interview Survey demonstrate that three-dose completion at 12 months of age increased form less than 1% of children born in 1989 to 40% of children born in the fourth quarter of 1992. Vaccination at birth increased from less than 1% of infants born in 1989 to 32% of infants born in the second half of 1993. CONCLUSIONS: Infant hepatitis B vaccination has expanded rapidly since national recommendations were made; however, universal coverage has not been achieved.

Hospital-based evaluation of programs to prevent perinatal hepatitis B virus transmission.

OBJECTIVE: To evaluate the frequency of hepatitis B surface antigen (HBsAg) screening of pregnant women in the United States and factors associated with the lack of screening. DESIGN: A random sample of 200 hospitals with 100 or more births per year was surveyed with regard to policy and practices. Each hospital was also asked to provide maternal screening and infant follow-up data for the first 25 infants who were born on or after March 1, 1993. RESULTS: Of 183 participating hospitals, 137 (75%) had maternal HBsAg screening policies, and 102 (56%) had standing orders for HBsAg testing of pregnant women who were admitted without prior screening. Hospitals that were located in states with laws that required maternal HBsAg screening were more likely to have a written screening policy (prevalence ratio [PR], 1.7; 95% confidence interval [CI], 1.2-2.4) and a standing order (PR, 1.7; 95% CI, 1.4-2.2). A lack of screening was related to delivery in hospitals without screening policies (PR, 3.4; 95% CI, 1.3-8.9) or standing orders (PR, 2.8; 95% CI, 1.2-6.2), and to the infant's provider being a family practitioner (PR, 1.7; 95% CI, 1.1-2.7). Among the 3982 infants for whom data were available, 3342 (84%) were born to mothers who had undergone screening for HBsAg. CONCLUSIONS: These findings suggest that hospitals should develop specific policies for HBsAg screening, states should enact laws that require maternal screening, and additional education of health care providers is needed with regard to the screening of all pregnant women for HBsAg.

Continuing risk for hepatitis B virus transmission among Southeast Asian infants in Louisiana.

OBJECTIVE: Implementation and evaluation of a hepatitis B vaccination program for Southeast Asian infants in Louisiana. METHODS: A baseline seroprevalence survey of hepatitis B virus (HBV) infection in US-born Southeast Asian children was conducted in 1991 before the implementation of a vaccination program. Hepatitis B vaccination and postvaccination serologic testing of survey participants 10 years of age and younger was performed. Eighteen months after the hepatitis B vaccine was integrated into infant immunization schedules in July 1993, a vaccination coverage survey was performed. RESULTS: Baseline serologic testing was conducted on 96% of persons from 225 randomly selected households in a Southeast Asian community in Louisiana. Of 676 US-born children, 28 (4.1%) had chronic HBV infection; 61% of children with chronic HBV infection were born to hepatitis B surface antigen (HBsAg)-negative women. Among children born to HBsAg-negative women, the prevalence of chronic HBV infection increased with age, reaching 7.3% for children 13 to 16 years of age. Children born to HBsAg-negative women and living with carriers were 5.4 times more likely to have evidence of HBV infection than were children who did not live with carriers. Before the survey, only one child had received three doses of hepatitis B vaccine. In July 1993, 43% of Southeast Asian infants 9 to 18 months of age born in Louisiana had received three doses of hepatitis B vaccine. Infants who received immunizations from private providers were more likely to be fully vaccinated than were infants who received services from public sector clinics (prevalence ratio, 2.1; 95% confidence interval, 1.4, 3.1). CONCLUSIONS: HBV transmission occurs throughout childhood in US-born Southeast Asian children, and the prevalence of chronic HBV infection approaches that of the country of origin. Few US-born Southeast Asian children have received hepatitis B vaccine. Because of the high rates of early childhood HBV transmission and the high risk of chronic infection in Asian and Pacific Islander communities, prevention efforts should be enhanced to ensure that all Asian and Pacific Islander infants receive hepatitis B vaccine in the first 12 months of life and that older children are vaccinated.

A hepatitis B vaccination program targeting adolescents.

PURPOSE: To determine the effectiveness of using a middle school for hepatitis B vaccination of adolescents. METHODS: An immunization program was designed to educate parents and students about hepatitis B virus (HBV) infection and hepatitis B vaccination using science class presentations and mailings. Students were given at each visit and on vaccination series completion. Costs were calculated and divided by the number of students completing the series to obtain per student cost. RESULTS: Of the 654 students, 519 (79%) received at least one dose of hepatitis B vaccine, 497 (76%) two doses, and 425 (65%) three doses. Student participation did not vary by grade level, gender, or income. Per student vaccination cost was $77.23 for those receiving three doses of hepatitis B vaccine and $66.04 when those receiving at least two doses were included. Of 103 students with postvaccination serologic testing, three had evidence of previous hepatitis B virus infection, four had no evidence of vaccine induced immunity, and 96 (96% of susceptible students) developed protective levels of antibodies against hepatitis B surface antigen. The geometric mean antibody titer among persons responding to vaccination was 661 mIU. CONCLUSION: Hepatitis B vaccination of adolescents can be successfully integrated into a middle school setting.

Impact of the bloodborne pathogens standard on vaccination of healthcare workers with hepatitis B vaccine.

OBJECTIVES: To evaluate the impact of Occupational Safety and Health Administration (OSHA) regulations on the vaccination of healthcare workers (HCWs), to assess interpretation of these regulations, and to evaluate changes in hospital vaccination policies. DESIGN: Between June 1, 1992, and August 15, 1992, a telephone survey was conducted among 150 hospitals selected randomly from participants in the American Hospital Association 1991 annual survey. RESULTS: Of the 150 hospitals, 96 (64%) provided information on hepatitis B vaccination coverage of their employees. Of the 103,419 employees in these hospitals, 77,302 (75%) were eligible to receive the hepatitis B vaccine, and 38,850 (51%) of these were vaccinated completely (had received 3 doses of vaccine). Following issuance of the final regulations, 73% of hospitals reported greater employee acceptance of hepatitis B vaccine, and hospitals were more likely to offer hepatitis B vaccine to maintenance workers, security personnel, dietary staff, and clerical personnel. Seventy-five hospitals (50%) reported conducting postvaccination serologic testing on all hospital employees, 12 (8%) as a result of OSHA regulations. Twenty-three hospitals (16%) reported administering routine booster doses of hepatitis B vaccine at 3, 5, or 7 years. CONCLUSIONS: The new OSHA standard resulted in a greater awareness of risk for HBV infection among HCWs and an increase in the number of HCWs receiving hepatitis B vaccine; however, vaccination coverage remained suboptimal. Postvaccination serologic testing of employees with negligible risk and the routine administration of vaccine booster doses may be diverting resources and preventing comprehensive coverage of high-risk employees.

Evaluation of an intervention program for the control of an outbreak of shigellosis among institutionalized persons.

After control measures were initiated to stop an outbreak of shigellosis in an institution for the developmentally disabled, there was a sharp decline in the number of cases of Shigella sonnei infection. Among ill residents, those treated with antibiotics had shorter mean duration of diarrhea (2.4 vs. 4.5 days, P < .01) and were less likely to have stool cultures positive for shigellae 2-4 weeks after onset of diarrhea (0/25 vs. 5/19; relative risk [RR] = undefined; P = .02). The attack rate was higher in villages where segregation of ill residents was not practiced (46/73 vs. 53/155; RR = 1.8; 95% confidence limits [CL], 1.4, 2.4). In individual housing units where ill residents were not segregated (preintervention), a correlation was found between mean duration of diarrhea and unit attack rates (r = .88; 95% CL, 0.29, 0.99). A study of all 305 residents 10 weeks after the intervention began revealed no positive stool cultures.

Prevention of hepatitis B virus infection.

Hepatitis B virus infection is the most important cause of acute and chronic liver disease worldwide. The Immunization Practices Advisory Committee has proposed a comprehensive strategy to eliminate the transmission of hepatitis B virus in the United States. The three phases of this strategy are prevention of perinatal transmission of the hepatitis B virus, universal vaccination of all infants against hepatitis B virus infection and selected vaccination of high-risk adolescents and adults. Because family physicians provide obstetric, perinatal, adolescent and adult care, they can have a major influence on the success of this strategy.

Effect of a hepatitis B vaccination program on the prevalence of hepatitis B virus infection.

In April 1991, surveys for serologic evidence of hepatitis B virus (HBV) infection were conducted among 3- to 4-year-old children born after a hepatitis B immunization program of newborns began and among 6- to 11-year-old children targeted for early childhood vaccination in American Samoa. Compared with 3- to 4-year-olds tested in 1991, children tested at baseline in 1985 were more likely to have been infected with HBV (5/40 vs. 2/93; prevalence ratio [PR] = 5.8, 95% confidence limits [CL] = 1.2, 28.7) and to have chronic infection with HBV (3/40 vs. 0/95; PR = undefined, lower CL = 1.2). Compared with 6- to 11-year-olds tested in 1991, children in 1985 were more likely to have been infected with HBV (32/121 vs. 53/386; PR = 1.9, CL = 1.3, 2.8) and to have chronic infection with HBV (8/121 vs. 7/386; PR = 3.6, CL = 1.3, 9.8). The incorporation of hepatitis B vaccine into routine childhood vaccination schedules can prevent acute and chronic HBV infection in areas of high endemicity.

An outbreak of hepatitis A associated with swimming in a public pool.

A multistate outbreak of hepatitis A was traced to a campground in Louisiana. Among 822 campers during one weekend, 20 developed hepatitis A. Case-patients ranged in age from 4 to 36 years; the highest attack rate (6.4%) was for children aged 5-9 years. A case-control study revealed that case-patients were more likely than controls to have swum in a public swimming pool on Saturday afternoon (19/19 vs. 26/38; odds ratio [OR], undefined; lower 95% confidence limit, 1.7). Case-patients were more likely than controls to have swum in the jacuzzi pool (16/19 vs. 10/26; OR, 8.0; 95% confidence interval, 1.5-47.1) or adult pool A (19/19 vs. 15/26; OR, undefined; lower 95% confidence limit, 2.6). Case-patients were also more likely to have swum for greater than 1 h and to have put their heads under the water. Because of the design of the filtering system of adult pool A, a cross-connection between a sewage line and the pool water intake line was possible. This outbreak may have been caused by transmission of hepatitis A through swimming; thus, swimming may serve as a mode of transmission of hepatitis A virus, especially among small children.